ISO 9001:2008 Quality Manual Clause 3.7.4

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1 ISO 9001:2008 Quality Manual Clause Strode Park Foundation for People with Disabilities

2 Approvals The signatures below certify that this Quality Manual has been reviewed and accepted, and demonstrates that the signatories are aware of all the requirements contained herein and are committed to ensuring their provision. Name Signature Position Date Prepared by Jacky Moat HR Support 03/04/12 Reviewed by Approved by David Dye Quality Meeting on 15/05/12 HR Manager/Quality Manager Amendment Record This quality manual is reviewed to ensure its continuing relevance to the systems and process that it describes. A record of contextual additions or omissions is given below: Page No. Context Revision Date Various Reviewed and updated by JM to include Platters Farm Lodge 2 April 2013

3 Contents CONTENTS 3 INTRODUCTION 5 QUALITY MANAGEMENT SYSTEM PROCESS APPROACH 5 1. SCOPE 6 2. REFERENCES 7 3. TERMS & DEFINITIONS 8 4. QUALITY MANAGEMENT SYSTEM INTRODUCTION DOCUMENTATION REQUIREMENTS General Quality Manual Control of Records MANAGEMENT RESPONSIBILITIES MANAGEMENT COMMITMENT CUSTOMER FOCUS QUALITY POLICY PLANNING Quality Objectives Quality Management System Planning RESPONSIBILITY, AUTHORITY AND COMMUNICATION Responsibility and Authority Management representative Internal Communication MANAGEMENT REVIEW General Review Input Review Output RESOURCE MANAGEMENT PROVISION OF RESOURCES HUMAN RESOURCES General Competence, Awareness & Training INFRASTRUCTURE WORK ENVIRONMENT SERVICE DELIVERY REALIZATION PLANNING CUSTOMER RELATED PROCESSES Determination of Requirements Related to Service Review of Requirements Related to Product Customer Communication DESIGN & DEVELOPMENT 18 STRODE PARK FOUNDATION DOES NOT ENGAGE IN THE DESIGN OR MANUFACTURE OF PRODUCTS AND OFFERS SERVICE ONLY. TO THIS END OUR QUALITY MANAGEMENT SYSTEM DOES NOT ENCOMPASS PRODUCT DESIGN AND DEVELOPMENT PROCESSES AND THEREFORE PARAGRAPH 7.3 IS NOT APPLICABLE TO OUR BUSINESS AND HAS BEEN EXCLUDED Purchasing Process Purchasing Information Verification of Purchased Product SERVICE PROVISION Control of Service Provision 19

4 7.5.2 Customer Property CONTROL OF MONITORING & MEASURING EQUIPMENT MEASUREMENT, ANALYSIS & IMPROVEMENT GENERAL MONITORING & MEASUREMENT Customer Satisfaction Internal Audit Process Monitoring & Measurement Product Monitoring & Measurement CONTROL OF NON-CONFORMING SERVICE ANALYSIS OF DATA IMPROVEMENT Continual Improvement Corrective Action Preventive Action 23 APPENDICES 24 A.1 ABBREVIATIONS & ACRONYMS 24 A.3 LIST OF KEY QMS DOCUMENTS 26 Procedures 26 Forms 27 A.4 ORGANISATIONAL CHART 27

5 Introduction Strode Park Foundation has developed and implemented a Quality Management System in order to document the Foundation s best business practices, better satisfy the requirements and expectations of its service users and stakeholders and to improve the overall management of the Foundation. The Quality Management System of Strode Park Foundation meets the requirements of the international standard ISO 9001: This system addresses the development, production, installation of the Foundation s services. This manual describes the Quality Management System, delineates authorities, inter relationships and responsibilities of personnel responsible for performing within the system. The manual also provides procedures or references for all activities comprising the Quality Management System to ensure compliance to the necessary requirements of the standard. This manual is also used externally to introduce our Quality Management System to our service users and stakeholders, and other external organizations or individuals. The manual is used to familiarise them with the controls that have been implemented and to assure them that the integrity of our Quality Management System is maintained and focused on customer and stakeholder satisfaction and continuous improvement. Quality Management System Process Approach Continual Improvement of the Quality Management System Service users/customers (and other interested parties ) Management Responsibility Service users/customers (and other interested parties) Resource Management Measurement analysis and improvement Satisfaction Requirements Service realisation Service Output The model above illustrates that effectiveness and improvement can be represented as a cyclical process that uses components of the Quality Management System to analyze data and then direct changes and initiatives that ensure the system s continual improvement. This ensures a proactive approach to meeting the Quality Management System objectives and customer and stakeholder requirements.

6 1. Scope The activity covered by Strode Park Foundation is for the provision of specialist care, rehabilitation and support services for children and adults with complex disabilities including leisure services and respite care. The Quality Management System complies with all applicable requirements contained in ISO 9001:2008, covers the provision of all products and/or services, and encompasses all operations at our facility located at Strode Park House, Herne, Herne Bay CT6 7NE; Footprints and Redwalls, Stodmarsh Road, Canterbury CT3 4AP; Platters Farm Lodge, Highfield Road, Gillingham, ME8 0EQ The following table identifies ISO 9001:2008 requirements not applicable to the Foundation and provides a brief narrative justifying their exclusion from the scope of the Quality Management System: Clause Justification 7.3 Design & Development Strode Park Foundation offers a service only

7 2. erences In addition to ISO 9001:2008, the Foundation will also make reference to relevant British and or international standards as well as service user/stakeholder specifications appropriate to the service delivery and its market. Standard Title ISO 9000:2005 Quality Management Systems Fundamentals and vocabulary ISO 9001:2008 Quality Management Systems Requirements ISO 9004:2000 Quality Management Systems Guidelines for performance improvements

8 3. Terms & Definitions Our Quality Management System uses the same internationally recognised terms, vocabulary and definitions given in ISO 9000:2005. Acronyms, terms, vocabulary and definitions unique to our organization, customers, industry and region are referenced throughout our Quality Manual and are contained in Appendix A.1. The following terms and definitions are taken from ISO 9000:2005: Term ISO Clause Definition Document Information and its supporting medium Procedure Specified way to carry out an activity or a process Quality Manual Document specifying the quality management system of an organization Quality Plan Document specifying how procedures and resources shall be applied Record Document stating results achieved or evidence of activities performed Specification Document stating requirements

9 4. Quality Management System 4.1 Introduction The Foundation has implemented a Quality Management System that exists as part of a larger, overall management system which has established, documented and implemented our quality policy and related processes for providing products and services which meet or exceed service user and stakeholder requirements, whilst satisfying the requirements of ISO 9001:2008. The Foundation has adopted the process approach advocated by ISO 9000:2005, by defining and managing process inputs, controls and outputs to ensure the desired results are achieved and by managing the interfaces between interrelated processes to ensure system effectiveness is maintained. The Foundation monitors, measures and analyzes relevant processes and takes action to achieve planned results and ensures the continual improvement of our Quality Management System. Any outsourced process or activity is controlled as per applicable ISO 9001 requirements. Specific responsibilities for, and the sequence and interaction of key quality management system processes are detailed in the quality procedures, some of which contain or reference deployment flow charts depicting the process or which is also described in the narrative of the procedure. Appendix A.2 describes the sequence and interaction of our organizational processes. 4.2 Documentation Requirements General This Quality Manual contains documented statements of our quality policy and quality objectives and references the documented procedures required by ISO 9001:2008 and other documents needed to ensure effective planning, operation and control of our key processes. The level and type of Quality Management System documentation established for our business is continually reviewed to ensure it remains appropriate for the complexity of the interactions of our core processes and the competence of our employees. Quality Management System documents and data exist in hard copy and electronic format. The Quality Management System documentation includes this quality manual, quality procedures, forms and other internal and external documents and data needed to manage, perform or verify work affecting service delivery quality. Any Quality Management System documentation which is utilized or generated is categorised into the following hierarchy: Quality Management System Documentation Hierarchy: Tier Document Type Purpose 1 Policy Key system driver of process inputs and objectives; statement of corporate vision 2 Quality manual Describes corporate approach and responsibilities for achieving quality 3 Procedures Describe the methods required for process implementation 4 Work instructions Describe the operating practices and controls of each process 5 Forms Key system outputs; data, records, proof of conformance and evidence of verification Quality Manual This manual has been prepared to describe the Foundation s Quality Management System; its associated procedures, and the processes needed to implement our Quality Policy in order to achieve our quality objectives. Each section of the manual makes reference to various procedures, forms and process maps relating to the requirements outlined in that section Document Control All Quality Management System documents are controlled according to the Document Control Procedure (PR001) and Document Control Policy (P001-3) which define the process for: Approving documents for adequacy prior to issue

10 Reviewing and revising as necessary and re-approving documents Ensuring that changes and current revision status of documents are identified Ensuring that relevant versions of applicable documents are available at points of use Ensuring that documents remain legible and readily identifiable Ensuring that documents of external origin are identified and their distribution controlled Preventing the unintended use of obsolete documents Ensuring that documents of external origin are identified and their distribution controlled The Foundation uses standard forms and a local area network computer system with an electronic document Management system which are updated as required. Documents which must be controlled include but are not limited to the followings examples: Quality manual Procedures Records Controlled documents are identified with a document name and document number: Policies are prefixed with P Procedures are prefixed PR Forms are prefixed F Work instructions are prefixed W Meeting agendas are prefixed M A list of key Quality Management System documents; including all quality procedures, forms and other key quality management system documents is located in Appendix A.3. PR001 Document Control Procedure P001-3 Document Control Policy Control of Records Records are established to provide evidence of conformity to the requirements specified by the standard, customer and stakeholder requirements and of the effective operation of the Quality Management System are formally controlled through the application of the Control of Records Procedure (PR002). Records which are controlled include but are not limited to: Corrective Action Reports Management Review Reports Customer Complaints Calibration Records PR002 Control of Records Procedure

11 5. Management Responsibilities Senior Management has the responsibility and authority for supporting the development and implementation of the Quality Management System, for ensuring that it remains relevant to the Foundation s objectives, and the needs and expectations of service users and stakeholders whilst promoting an ethos of continual improvement. Senior Management and their direct reports are responsible for communicating the quality policy as well as the importance of meeting service user, statutory and regulatory requirements to employees within their respective Departments. They ensure the policy is understood and that it is applied to the daily work of the organization through the establishment of measureable goals and objectives. Senior Management is responsible for ensuring that the quality policy is appropriate for the goals of the business, that it promotes the continuing improvement of the effectiveness of the Quality Management System and that it is reviewed for continuing suitability. All managers are responsible for communicating business plans and organizational goals within their respective Departments and reporting back to the organization on the performance and effectiveness of the Quality Management System. 5.1 Management Commitment The Directors of Strode Park Foundation are committed to implementing and developing the quality management system and this commitment is defined by the Quality Policy located in Section 5.3. We ensure that our Quality Policy is understood, implemented and maintained at all levels of the organization through printed distribution of our Quality Policy statement and through periodic management review of the Quality Policy statement and corporate level improvement objectives. In addition, our Quality Policy and objectives are communicated and deployed throughout the business via individual performance objectives established and reviewed during employee performance reviews. All managers demonstrate their commitment to the development and improvement of the Quality Management System through the provision of necessary resources, through their involvement in the internal audit process and through their proactive involvement in continual improvement activities. Emphasis is placed on improving both the effectiveness and efficiency of key Quality Management System processes. 5.2 Customer Focus The Foundation strives to identify current and future service user needs, to meet their requirements and to exceed their expectations. Senior Management ensures that the focus on improving service user satisfaction is maintained by setting and reviewing objectives related to customer satisfaction at management review meetings. Senior Management also ensures that service user and stakeholder requirements are understood and met. Service user and Stakeholder requirements are understood converted into internal quality requirements and communicated to appropriate personnel within the organization. Customer complaints and other customer feedback is continually monitored and measured to identify opportunities for improvement. We continually look for other ways to interact directly with individual service users to ensure a proper focus to their unique needs and expectations is established and maintained. 5.3 Quality Policy Senior management ensures that the quality policy is communicated and understood by all employees at all levels of the organization through documented training, regular communication, and reinforcement during annual employee performance reviews. Our Quality Policy statement acts as a compass in providing the direction and framework for establishing key corporate level performance measures and related improvement objectives as per Section Senior Management reviews the quality policy during management review meetings to determine the policy s continuing suitability.

12 5.4 Planning Quality Objectives Quality objectives are established to support our organization s efforts in achieving our Quality Policy and are reviewed annually for continuing suitability. Quality objectives are measurable and reviewed against performance goals during scheduled management review meetings. 1. Manage and control facilities, processes, quality systems and personnel to consistently and cost effectively and furnish services that meet service user and stakeholder needs (Section 7.5.1) 2. Conduct operations in conformance with, or to exceed, all applicable laws and regulations of the jurisdictions in which we do business (Section 6.4) 3. Be committed to continuous process improvement (Section 8.5) by emphasising reduction of part-to-part variation and the elimination of all waste 4. Achievement of ZERO DEFECTS and 100% on time delivery (Section 7.5.1) performance Quality Management System Planning The quality system has been planned and implemented to meet our quality objectives and the requirements of Section 4.1 of ISO 9001:2008. The quality planning process involves establishing and communicating our Quality Policy and objectives through issuance of this manual and its associated procedures. Accordingly, this manual constitutes our overall plan for establishing, maintaining and improving the system. For each instance of Quality Management System planning, the output is documented accordingly and changes are conducted in a controlled manner. Our Management review and internal audit processes ensure the integrity of our Quality Management System is maintained when significant changes are planned and implemented which affect key system processes. 5.5 Responsibility, Authority and Communication Responsibility and Authority An organizational structure is defined in Appendix A.4. The organization chart shows the interrelation of personnel within the organization whilst job descriptions define the responsibilities and authorities of each role. Job descriptions and the organizational structure are reviewed and approved by Top Management for adequacy. Members of Senior Management are ultimately responsible for the quality of the Foundation s services since they control the systems and processes by which conforming work is accomplished. Senior Management is responsible for business planning, development and communication of our Quality Policy, Quality Management System planning, the establishment and deployment of objectives, the provision of resources needed to implement and improve the Quality Management System and for undertaking management reviews. All managers are responsible for execution of the business plan and the implementation of the policies, processes and systems described in this manual. All managers are responsible for planning and controlling Quality Management System processes within their area of responsibility, including the establishment and deployment of operational level objectives and the provision of resources needed to implement and improve these processes. All employees are responsible for the quality of their work and implementation of the policy and procedures applicable to processes they perform. Employees are motivated and empowered to identify and report any known or potential problems and to recommend related solutions by the corrective/preventive action process. Quality and Environmental Management Structure Overall Responsibility: Council of Management Report in September, if approved, to be included in Annual Report for AGM Executive Committee Receives reports from the Quality Committee

13 Day to Day responsibility: Quality Committee Senior Managers Quality Issues Monthly Management Meeting to approve all changes and receive regular reports. Every quarter receive formal reports on quality and environmental matters from Quality Manager and Director of Care. Reporting to the Quality Issues Monthly Management Committee: Monthly incident and exception reports to Quality Committee and full report every quarter, on progress against targets and on all audits and service user satisfaction indicators o o o o o Senior Manager s meeting: Responsible for implementation and monitoring of Service Quality, complaints (unless raised at a higher level or with the Health & Safety and Environmental Committee), Care Quality Audits, all Stakeholder feedback (compliments and complaints, quality assessment visits, business continuity. Health, Safety & Environmental Management Committee All accidents and incidents, relevant complaints, Health & Safety and Environmental Audits Clinical Governance Committee All Clinical Governance matters and audit Training erence and Staffing Group HR with Service Managers, Finance Director and Care Director. Managers to provide input from supervisions and appraisals Marketing Review Group Marketing with Service Managers and Care Directors Other meeting minutes are submitted to the Quality Committee: Staff Meetings, Staff Representative Meetings Management representative Training outcomes and audit, training plans. The Foundation has appointed a Quality Management Representative (the HR Director) with delegated responsibilities for ensuring that a compliant Quality Management System is established, implemented, and maintained; for promoting awareness of customer and stakeholder requirements throughout the organization; Section 5.5.3; and for ensuring that the performance of the Quality Management System is reviewed by Top Management for effectiveness, continuing suitability and the need for improvement; Section 5.6. The Quality Management Representative has the following responsibilities: Ensure that processes needed for the Quality Management System are established and implemented Act as a liaison with external parties on matters relating to the QMS Report to top management on the performance of the Quality Management System Promote awareness of service user and stakeholder requirements throughout the organization Organizational freedom to resolve matters pertaining to quality Resolve matters pertaining to quality issues Promote initiatives for improvement Internal Communication The Foundation communicates information regarding Quality Management System processes and their effectiveness through documented training, internal audit reports and continual improvement processes. All managers and supervisors are responsible for establishing regular formal and informal communications as needed to convey to their employees the relevance and importance of their activities; typically this information is conveyed through team meetings and cross-functional improvement projects.

14 Communications regarding how employees contribute to the achievement of objectives is also conveyed and reinforced during employee performance reviews. PR003 Internal Communication Procedure 5.6 Management Review General Senior Management conducts a management review meeting at least once a year to ensure the continuing suitability, adequacy, and effectiveness of our Quality Management System. The primary inputs reviewed include data that measures the conformance and performance of our Quality Management System and recommendations based on analysis of such data. Conformance is primarily assured through internal audits and demonstrated through a review of audit results and our demonstrated ability to correct and to prevent problems. Performance is primarily assured through the deployment of corporate and operational level objectives, and through a review of our demonstrated ability to achieve desired results. The primary outputs of Management review meetings are management actions taken to make changes or improvements to our Quality Management System and the provision of resources needed to implement these actions Review Input Assessment of the quality management system is based on a review of information inputs to management review. These inputs can include the following: Planned changes that could affect the Quality Management System Process performance and product conformity Status of preventive and corrective actions Recommendations for improvement Foundation level quality data Customer feedback Results of audits Review Output During management review meetings, Senior Management will identify appropriate actions to be taken regarding the following issues: Improvement of the effectiveness of the Quality Management System and its processes Improvement of services related to service user and stakeholder requirements Resource needs The primary outputs of Management review meetings are management actions taken to make changes or improvements to our Quality Management System and the provision of resources needed to implement these actions. Responsibilities for required actions are assigned to members of the management review team. Any decisions made during the meeting, assigned actions, and their due dates are recorded on the management review presentation. PR004 Management Review Procedure

15 6. Resource Management 6.1 Provision of Resources During planning and budgeting processes and as needed throughout the year, Senior Management determine and ensure that appropriate resources are available to implement and maintain the Quality Management System and to continually improve its effectiveness whilst enhancing customer satisfaction by meeting their requirements. 6.2 Human Resources General To ensure competence of our personnel, job descriptions have been prepared identifying the qualifications required for each position that affects service delivery quality. Qualifications include desired requirements for education, skills and experience. Appropriate qualifications, along with required training, provide the competence required for each position Competence, Awareness & Training All employees are trained on the relevance and importance of their activities and how they contribute to the achievement of the quality objectives. The company operates a formal system to ensure that all employees within the organization are adequately trained to enable them to perform their assigned duties. Qualifications are reviewed upon hire, when an employee changes positions or the requirements for a position change. The Human Resources Department maintains records of employee qualifications. If any differences between the employee s qualifications and the requirements for the job are found, training or other action is taken to provide the employee with the necessary competence. The results are then evaluated to determine if they were effective. Senior Management identifies emerging competency needs during Management reviews; Section 5.6. Emergent competency needs are converted into job descriptions for the type and number of positions that need to be filled through internal or external recruitment. Where possible; training is conducted in-house, although for more specialist skills, external seminars or courses are utilized. The effectiveness of training is evaluated. The Foundation induction includes an introduction to the Foundation s quality policy statement and objectives. Future training needs are identified as part of the Management Review process. Training records are maintained to demonstrate competency and experience. Human Resources will review the training records annually to ensure completeness and to identify possible future training needs. Training records are maintained in accordance with Section and include as a minimum, the following information: Copies of certificates for any training undertaken to date Current Job Description Curriculum Vitae P005 Training and Awareness Procedure 6.3 Infrastructure The Foundation is responsible for planning, providing and maintaining the resources needed to achieve product conformance, including buildings, workspace and associated utilities; process equipment (hardware and software); and supporting services (such as internal transportation and material handling systems and communications systems). The Facilities Manager has overall responsibility for managing our facilities and equipment maintenance programs which include: Transportation and material handling equipment management, maintenance and repair Service equipment management, maintenance and repair

16 Facilities management, maintenance and repair The Director of Care has overall responsibility for: Hotel Services within Strode Park House The Manager of Footprints has responsibility for Hotel services management for Footprints with overall responsibility by the Director of Care The Manager of Redwalls has responsibility for Hotel services management for Redwalls with overall responsibility by the Director of Care The Manager of Platters Farm Lodge has responsibility for Hotel services management for Platters Farm Lodge with overall responsibility by the Director of Care. The Systems Administrator has overall responsibility for: Information systems maintenance and repair PR006 Facilities Management Procedure 6.4 Work Environment The Foundation ensures that the buildings and grounds comply with relevant health and safety regulations e.g. personnel are issued with hi-visibility jackets, risk assessments are carried on plant, material safety data sheets and COSHH data sheets are retained for the various substances used within the service. In addition, the Health, Safety & Environmental Management Committee carries out regular audits to ensure that standards are maintained. In addition, all personnel are encouraged to contribute to the success of this policy via its open door policy.

17 7. Service Delivery Realization 7.1 Planning The Foundation has established documented quality plans and procedures that describe processes and controls to be applied and the records required. During this planning phase, management or assigned personnel will identify: The quality objectives and requirements for the service are developed for all new projects Verification, validation, monitoring, inspection and test requirements Processes, documentation and resources required Criteria for service acceptance Resources necessary to support operation and maintenance of the service The output of quality planning includes documented quality plans, resource requirements, processes, equipment requirements, procedures and service delivery. PR007 Service Delivery Realization & Planning Procedure 7.2 Customer Related Processes Determination of Requirements Related to Service The Foundation determines customer requirements before acceptance of a new service user Customer requirements include the following: Assessment carried out by Foundation staff Requirements stated by the customer Statutory and regulatory requirements related to the service Requirements required for service delivery and post-delivery activities Additional requirements determined by the Foundation Review of Requirements Related to Product Prior to committing to the customer, the Foundation has a process in place for the review of requirements related to the service. The review is conducted before the contract is accepted. The process ensures that: Service requirements are defined The Foundation has the ability to meet the defined requirements Records are maintained showing the results of the review and any actions arising Service User requirements are confirmed before acceptance When service requirements are changed, the organization communicates changes to personnel and amends relevant documents PR008 Care Plan Review Procedure

18 7.2.3 Customer Communication In accordance with our commitment to exceed our customer s expectations, the Foundation highlights effective customer communication as an essential element of customer satisfaction. Appropriate handling of customer communication will help to reduce customer dissatisfaction and in many cases turn a dissatisfying scenario into a satisfying experience. The Departmental Managers and Marketing Department are responsible for establishing communication methods to ensure enquiries, contracts or order handling; including amendments, customer feedback and complaints are handled expeditiously and professionally. The Fundraising and Marketing Department s primary responsibility is ensuring that appropriate people know about the Foundation services. Departmental Managers are the primary customer contacts for service information. The Director of Care is committed to addressing all documented customer enquires that reside within the organization s system. The Service Managers have the primary responsibility to address all customer related issues in regard to the quality of our services. The Quality Management Representative is the key contact in regard to questions pertaining to the Foundation s Quality Management System. 7.3 Design & Development Strode Park Foundation does not engage in the design or manufacture of products and offers service only. To this end our Quality Management System does not encompass product design and development processes and therefore paragraph 7.3 is not applicable to our business and has been excluded Purchasing Process The purchasing process is essential to the Foundation s ability to provide our service users with services that meet their requirements. The Foundation ensures that purchased product conforms to specified purchase requirements. The Foundation accomplishes this by closely working with our supplier base (e.g. periodic audits and surveys) and inspecting purchased product as required. The type and extent of control applied to the supplier and the purchased product is dependent upon the effect of the purchased product on subsequent services. It is the responsibility of the relevant department to evaluate and select suppliers based on their ability to supply product in accordance with specified requirements. Additionally, other internal resources may be called on to assist as required. Criteria for selection, evaluation and re-evaluation are defined in the Purchasing Procedure. Records of the results of evaluations and any necessary actions arising from the evaluation are maintained within the Foundation documentation system Purchasing Information The Foundation uses purchase orders to describe the product or service to be purchased. Designated individuals within the company create purchase orders using the company system. They also ensure the adequacy of the requirements that are specified by the purchase order prior to release. Each purchase order includes where appropriate: Identification of product or service to be delivered, quantity, delivery date, and cost Requirements for approval or qualification of product, procedures, processes or equipment Requirements for the qualification of personnel Quality Management System requirements Verification of Purchased Product Purchased items are checked against the purchase order to confirm identity and quantity. Satisfactory items are placed in stock or utilised. In the event that items are rejected on receipt the supplier is contacted to arrange replacement or credit. Where the customer wishes to verify supplier activities, specific arrangements will be made. PR010 Purchasing Procedure

19 7.5 Service Provision Control of Service Provision In order to control the planning, administrative support and implementation of work, the Foundation s policy is to describe the work methods, the controls applied and the records required. The process control activities are integrated through the care plans with many aspects that also relate to quality control. The following controlled conditions are applied where applicable: Quality control checks are performed using appropriate measuring equipment where possible Evidence of completed inspections Detailed care instructions Criteria for care Competent personnel Planned maintenance PR011 Care Plan Control Procedure PR012 PR015 Care Plan Review Procedure Preservation of Care Plan Procedure Customer Property The care of all service users property is to be covered by local procedures. This is because appropriate care varies between service users and departments. Money which the Foundation takes responsibility for is to be controlled by the Finance Department under their policy. PR014 Control of Customer Property Procedure 7.6 Control of Monitoring & Measuring Equipment The Foundation has determined the monitoring and measurement to be undertaken and the devices needed to provide evidence of conformity to determined requirements. Where necessary to ensure valid results, measuring equipment is: Calibrated or verified at specified intervals, or prior to use, against measurement standards traceable to international or national measurement standards Software which is used for monitoring and measurement is validated according to defined parameters prior to use Protected from damage and deterioration during handling, maintenance and storage Safeguarded from adjustments that would invalidate the measurement result Identified to enable the calibration status to be determined Adjusted or re-adjusted as necessary In addition, the Facilities Department assesses and records the validity of previous measurement results when the equipment is found not to conform to requirements. The Facilities Department takes appropriate action on any equipment or product affected. Where equipment is found to be out of calibration, the significance of the error is reviewed and appropriate action taken. Records of the results of calibration and verification are maintained.

20 8. Measurement, Analysis & Improvement 8.1 General This section describes how we define, plan and implement monitoring, measurement, analysis and improvement activities needed to assure service and quality system conformity and to achieve continual improvement. These activities include the assessment of customer satisfaction, internal auditing, service monitoring and measurement, and service delivery monitoring and measurement. The Director of Care ensures that statistical tools are used to monitor Quality Management System processes; these are identified during quality planning and are included in control plans. Statistical techniques for on-going service control and improvement are established and are applicable to customer specific requirement documents. The Foundation plans and implements monitoring, measurement, analysis and improvement processes as needed, these processes are identified in documented procedures and include the determination of applicable methods, including statistical techniques and the extent of their use. To demonstrate conformity of the service To ensure conformity of the Quality Management System To continually improve the effectiveness of the Quality Management System 8.2 Monitoring & Measurement Customer Satisfaction The Quality Management Representative and Director of Care monitor information relating to customer perception as to whether the organization has fulfilled customer requirements. Customer complaints, whether received in writing, verbally or electronically through are immediately forwarded to the appropriate Manager for action. If the problem cannot be resolved, the complaint is transferred to the appropriate Director or Chief Executive following the Foundation s Complaints procedure. Customer survey data along with other customer feedback, including written or verbal complaints and information collected via the customer feedback form are reviewed by the Director of Care who initiates appropriate corrective actions needed as required by Section 8.5. Customer satisfaction is monitored in various ways: Analysis of customer complaints Customer satisfaction surveys Levels of repeat business Recognition and awards Growth of key accounts PR Internal Audit Customer Satisfaction Procedure Internal audit results are critical inputs that help in assessing the effectiveness of the Quality Management System by identifying opportunities for improvement, by promoting awareness of service user requirements and by measuring the effectiveness of the Quality Management System. The Foundation conducts internal audits at planned intervals to determine whether the Quality Management System conforms to the planned arrangements for service delivery realization, to the requirements of ISO 9001:2008, as well as to Quality Management System requirements. The Foundation will then determine if the Quality Management System is effectively implemented and maintained.

21 The Internal Audit Procedure (PR018) details the requirements for developing the audit program including the requirements for planning; taking into consideration the status and importance of the service delivery and areas to be audited, as well as the results of previous audits. The audit criteria, scope, frequency and methods are defined by the audit plan. The selection of auditors and their conduct ensures objectivity and impartiality throughout the audit process. Process owners do not audit their own work. In cases where it is not possible to conduct an objective audit; the services of independent external auditor will be sought. PR018 Internal Audit Procedure Process Monitoring & Measurement The Foundation applies suitable methods for monitoring and measuring all Quality Management System processes. Quality Management System processes are documented, measured, controlled and evaluated to ensure they are effective in achieving the desired results and to identify opportunities for improvement. In-process checks are included in various service processes and relate to both quality control and service delivery checks Provision is made for the identification and resolution of non-conformance. The emphasis is to prevent any problems which might affect customer satisfaction Action is taken promptly to resolve any problems that arise Regular care checks are performed and recorded Where specific inspection points are required these are identified in the care plan Product Monitoring & Measurement. Evidence of conformity with the care plan is maintained. Measurement requirements necessary for service acceptance are documented. 8.3 Control of Non-conforming Service It is the foundation s policy to detect, control and rectify any aspect of non-conformance as quickly and efficiently as possible. Where necessary, any service that does not conform to specified requirements is properly identified and controlled. Improvements are then implemented to ensure the non-conformance does not reoccur. The Foundation ensures that services which do not conform to specified requirements are identified and controlled to prevent unintended use. The controls and related responsibilities and authorities for dealing with non-conforming service are defined in the Control of Nonconforming Service Procedure (PR020). PR020 Non-conformance Procedure 8.4 Analysis of Data Senior Management and other managers and supervisors collect and analyze data using appropriate statistical techniques to determine the suitability and effectiveness of key quality management system processes applicable to their area(s) of responsibility and to identify opportunities for improvement. At a minimum, data is analyzed to assess achievement of the corporate level quality objectives, and service user and stakeholder requirements. A service is effective if the desired results are measurably achieved. Effectiveness is measured in terms of service quality, cost and budgetary performance, employee function performance against established objectives and customer satisfaction. The Foundation monitors trends in the following activities:

22 Characteristics of processes, services and their trends, refer to and Conformity to service delivery requirements, refer to Customer Satisfaction data, refer to Suppliers, refer to 7.4 Employees utilizing statistical tools to manage, verify or perform work will have attended an overview on basic concepts to ensure they are understood and properly utilized throughout the organization. PR021 Analysis of Data Procedure 8.5 Improvement Continual Improvement The Foundation continually improves the effectiveness of its Quality Management System through the effective application of the quality policy, quality objectives, auditing and data analysis, corrective and preventive actions and management reviews. The continual improvement process begins with the establishment of our quality policy; Section 5.3 and objectives for improvement; Section 5.4.1, based on objectives contained in our business plan. Customer satisfaction, internal audit, process and service delivery performance data, and the cost of poor quality are then compared to progress against objectives or KPIs to identify additional opportunities for improvement. The overall effectiveness of a continual improvement program (including corrective and preventive actions taken as well as the overall progress towards achieving corporate level improvement objectives) is assessed through our management review process Corrective Action Evidence of non-conformance, customer dissatisfaction or service weakness is used to drive our corrective action system. Since problems may exist, they will require immediate correction and possible additional action aimed at eliminating or reducing the likelihood of its recurrence. Management with responsibility and authority for corrective action are notified promptly of service delivery non-conformities. Investigating and eliminating the root cause of these failures is a critical part of our continual improvement process. The Foundation takes action to eliminate the cause of non-conformities in order to prevent recurrence. Corrective actions are appropriate to the effects of the non-conformities encountered. The documented Corrective Action Procedure (PR023) defines the requirements for: Reviewing non-conformities (including customer complaints) Determining the causes of non-conformities Evaluating the need for action to ensure that non-conformities do not recur Determining and implementing action needed Records of the results of action taken (see Section 4.2.4) Reviewing corrective action taken Follow-up audits are conducted in accordance with the internal audit process; Section 8.2.2, to ensure that effective corrective action is taken and that the action is appropriate to the impact and nature of the problem encountered. In addition, the Director of Care summarizes and analyzes corrective action data to identify trends in order to assess the overall effectiveness of the corrective action system and to develop related recommendations for improvement. The corrective actions are considered effective if the specific problem was corrected and data indicates that the same or similar problems have not recurred. Results of data analysis and subsequent recommendations are presented to Top Management for review.

23 PR023 Corrective Action Procedure Preventive Action The Foundation determines any necessary action to eliminate the causes of potential non-conformities in order to prevent their occurrence. Preventive actions are appropriate to the nature of a potential problem. Data from internal audits, customer feedback, employee suggestions, and other appropriate data is collected and analyzed to identify the actions needed to eliminate the causes of potential. Investigating and eliminating the root cause of potential failures is a critical part of our continual improvement process. We review and initiate preventive actions through our preventive action process defined below. The preventive action system is considered to be effective where potential risks or losses are avoided. A documented Preventive Action Procedure (PR024) defines the requirements for: Determining potential nonconformities and their causes Evaluating the need for action to prevent occurrence of nonconformities Determining and implementing action needed Records of results of action taken Reviewing preventive action taken PR024 Preventive Action Procedure

24 Appendices A.1 Abbreviations & Acronyms The following abbreviations and acronyms apply to this document: BS CA CAR CE CI IA ISO NC NCR PA PAR PO QA QC F QI QM QMR QMS P Definition British Standard Corrective Action Corrective Action Request Conformité Européenne Continuous Improvement Internal Audit International Standards Organization Non-conformance Non-conformance Report Preventive Action Preventive Action Request Purchase Order Quality Assurance Quality Control Quality Form Quality Improvement Quality Manual Quality Management Representative Quality Management System Quality System Procedure

25 A.2 Sequence and Interaction of Quality Management System Processes QMS Processes Core Processes Organizational Processes Document Control Control of Records Internal Communication Management Review Training & Awareness Facilities Management General Requirements (4.1 & 4.2) Management Responsibility (5.1, 5.2, 5.3, 5.4, 5.6) Resource Management (6.1, 6.2, 6.3, 6.4) Human Resources Document Control Accounts/Finance Facilities/Infrastructure IT & Communication Care Planning Contract Review Customer Requirements Sales/Marketing Purchasing Care Plan Control Care Plan Validation Customer Property Calibration Care Plan & Service Delivery (7.1, 7.2, 7.4, 7.5, 7.6) Procurement Service Delivery Logistics Customer Satisfaction Customer Service Internal Auditing Inspection & Testing Non-conformances Analysis of Data Measurement, Analysis and Improvement (8.1, 8.2, 8.3, 8.4, 8.5) Continual Improvement Corrective/Preventive Action Customer Satisfaction

26 A.3 List of Key QMS Documents Procedures Procedure No. ISO 9001/QMS PR Document Control PR Control of Records PR Internal Communication PR Management Review P Training & Development PR Facilities Management PR Service Delivery Realization & Planning PR Care Plan Review PR Purchasing PR Care Plan Control PR Care Plan Process Validation PR Control of Customer Property PR Preservation of Care Plan PR Customer Satisfaction PR Internal Audits PR Control of Non-conformances PR Analysis of Data PR Corrective Action PR Preventive Action

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